(IOMIT's) SIR SEEWOOSAGUR RAMGOOLAM MEDICAL COLLEGE BELLE RIVE, MAURITIUS APPLICATION FORM FOR MBBS COURSE 2010-2011    000510/618 SIGN OF ISSUING AUTHORITY 1. ROLL NUMBER :-   (NOT TO BE FILLED BY CANDIDATE) 2. NAME OF THE APPLICANT :- 3. FATHER'S/GUARDIAN'S NAME :- 4. FATHER'S OCCUPATION :- 5. MOTHER'S OCCUPATION :- 6. ADDRESS FOR CORRESPONDENCE :- STATE :- PIN :- PHONE:- FAX :- 7. EMAIL:-     8. NATIONALITY:-     9. PASSPORT NO:-         EXPIRY DATE :-     10. DATE OF BIRTH:- 11.CENTER OF PREFERENCE:- --Select Center-- DELHI DURBAN KAULA LUMPUR MAURITIUS SHARJAH OTHERS 12.COURSE:- --COURSE-- MBBS 13.TOTAL MARKS AT 10TH /O LEVEL EXAMINATION OBTAINED MARKS TOTAL MARKS 14.SUBJECT WISE MARKS/GRADE IN THE CLASS 12TH /A LEVEL EXAMINATION OBTAINED MARKS/GRADE   TOTAL MARKS BIOLOGY :-       PHYSICS :-       MATHS :-       CHEMISTRY :-       ENGLISH :-       15. DETAILS OF THE QUALIFYING EXAMINATIONS CLASS 12TH/A LEVEL MATRICULATION OR EQUIVALENT: EXAMINATION SCHOOL/COLLEGE UNIVERSITY/BOARD YEAR OF PASSING & ATTEMPT COUNTRY XTH/O LEVEL XIITH/A LEVEL 16. LANGUAGES KNOWN:    ENGLISH FRENCH HINDI OTHER I7. WHETHER HOSTEL IS REQUIRED:   -- Please -- Yes No DECLARATION 1. I wish to apply for admission to the IOMIT's SSR Medical College, Mauritius and hereby declare that the above information is true and complete to the best of my knowledge. I am aware that if any information herein is found to be incorrect or in complete, my application will be rejected & admission will be cancelled. 2. lf admitted to SSR Medical College, I shall abide by its rules and regulations. 3. I have read and understood all the provisions contained in the prospectus and here by agree to abide by these provisions 4. l. The parent/guardian of the applicant hereby declare that I am aware of the financial obligations of admitting my son/daughter/ward to SSR Medical College. I agree to pay the tuition and other fees payable to the institution as fixed by tne IOMIT from time to time. I also affirm and endorse the declaration made above by my son/daughter/ward 5. I agree that registration of this application does not confer any right on me in respect of selection for admission, which is solely left to the discretion of the institution. DATE:- PAYABLE AT MAURITIUS IN THE NAME OF "INDIAN OCEAN MEDICAL INSTITUTE TRUST, Security Code:*